Pelvic Ring Stabilization Using Anterior Subcutaneous Internal Fixation in Bladder Exstrophy Repair

COMPLETE PRIMARY REPAIR OF EXSTROPHY

ObjectiveTo compare short‐term treatment effects of internal and external fixation in the treatment of complicated tibial plateau fractures by preoperative planning with 3D printing.MethodsSixty‐nine patients with tibial plateau fractures were examined. 3D printing was used to establish the model in all patients before the operation. Thirty‐four patients were treated with an external fixator (9‐Schatzker Type V, 25‐Schatzker Type VI) and 35 patients were treated with internal fixation (12‐Schatzker Type V, 23‐Schatzker Type VI). The time span of the study was 2 years after the operation. All patients were followed up in the clinic of the attending physician who recorded patient follow‐up information at the same time. Finally, the Rasmussen functional score, radiographic parameters, complication rates, hospital days and operative parameters of the two groups were analyzed.ResultsThe short‐term (within 2 years) Rasmussen score in the external fixation group was close to that of the internal fixation group; the differences were not significant (P > 0.05). The fractures were reduced adequately using both forms of surgical treatment. There is no significant difference between internal and external fixation in terms of radiographic parameters after 2 years (Mann–Whitney U‐tests, P > 0.05). Thrombosis was detected in 7 cases (2 external fixation, 5 internal fixation). Superficial infection was detected in 3 cases (1 external fixation, 2 internal fixation). Deep infection was detected in 3 cases (0 external fixation, 3 internal fixation). Knee stiffness was detected in 4 cases (2 external fixation, 2 internal fixation); 1 (2.7%) case of screw pullout occurred in the internal fixation group. The external fixation group had shorter operation times (172.94 ± 50.00 min vs 253.86 ± 64.59 min), less bleeding volume (395.88 ± 121.10 mL vs 864.29 ± 238.12 mL), and fewer days (17.03 ± 5.03 days vs 30.17 ± 8.64 days) of hospitalization compared to the internal fixation (t‐test, P = 0.00); subgroup analysis of all patients with complex tibial plateau fractures revealed that for patients with tibial plateau fracture type VI, the functional score of external fixation (26.79 ± 2.04) is better than that (25.54 ± 1.69) of internal fixation (t‐ test, P = 0.026) and the overall infection rate of external fixation is lower than that of internal fixation (χ2‐ test, P = 0.047).ConclusionUsing 3D printed models in combination with external fixation has more advantages for short‐term treatment of complex tibial plateau fractures. In particular, relatively better functional recovery and lower rates of infection can be achieved for Schatzker type VI fractures. The external fixation treatment was preferred in cases of Schatzker VI tibial plateau fractures.

The purpose of this study was to evaluate the biomechanical stability and compressive forces across the sacroiliac (SI) joint of an anterior internal fixator compared to the femoral distractor and external fixator for vertically unstable pelvic fractures. Five composite pelvises with a simulated APC type III injury fixed with a femoral distractor, external fixator, or anterior internal fixator were tested. A pressure-sensitive film (Tekscan) was placed in the disrupted SI joint recording the magnitude of force. Then, in a single-leg stance model (Instron machine), a load was applied through the sacrum. We recorded displacement at the pubic symphysis and SI joint using high-speed video. Peak load and displacement were measured, and axial stiffness was calculated. Values were compared using a Student's t-test (p < 0.05). The SI joint was compressed significantly (p < 0.001) more using the anterior internal fixator (18.9 N) and femoral distractor (18.6 N) than the two-pin external fixator (2.5 N). There was no significant difference between the anterior internal fixator and the femoral distractor in displacement at the SI joint. The pubic symphysis displaced less with the femoral distractor than the anterior internal fixator (5.5 mm vs. 4.1 mm; p < 0.05). The anterior pedicle screw internal fixator allows for indirect compression across the sacroiliac joint that is superior to two-pin external fixation and comparable to the femoral distractor. The anterior internal fixator may be an option for temporary anterior pelvic fixation in situations where external fixation or the femoral distractor have otherwise been used.

Distal radial fractures affect an estimated 80,000 elderly Americans each year. Although the use of internal fixation for the treatment of distal radial fractures is becoming increasingly common, there have been no population-based studies to explore the dissemination of this technique. The aims of our study were to determine the current use of internal fixation for the treatment of distal radial fractures in the Medicare population and to examine regional variations and other factors that influence use of this treatment. We hypothesized that internal fixation of distal radial fractures would be used less commonly in male and black populations compared with other populations because the prevalence of osteoporosis is lower in these populations, and that use of internal fixation would be correlated with the percentage of the patients who were treated by a hand surgeon in a particular region. We performed an analysis of complete 2007 Medicare data to determine the percentage of distal radial fractures that were treated with internal fixation in each hospital referral region. We then analyzed the association of patient and physician factors with the type of fracture treatment received, both nationally and within each hospital referral region. We identified 85,924 Medicare beneficiaries with a closed distal radial fracture who met the inclusion criteria, and 17.0% of these patients were treated with internal fixation. Fractures were significantly less likely to be treated with internal fixation in men than in women (odds ratio, 0.84; 95% confidence interval, 0.80 to 0.89) and in black patients than in white patients (odds ratio, 0.74; 95% confidence interval, 0.65 to 0.85). Patients were more likely to be treated with internal fixation rather than with another treatment if they were treated by a hand surgeon than if they were treated by an orthopaedic surgeon who was not a hand surgeon (odds ratio, 2.49; 95% confidence interval, 2.29 to 2.70). Use of internal fixation ranged from 4.6% to 42.1% (nearly a ten-fold difference) among hospital referral regions. The percentage of patients treated with internal fixation within a hospital referral region was positively correlated with the percentage of patients in that region who were treated by a hand surgeon (correlation coefficient, 0.34; p &lt; 0.0001). The use of internal fixation for the treatment of a distal radial fracture differs widely among geographical regions and patient populations. Such variations highlight the need for improved comparative-effectiveness data to guide the treatment of this fracture.

To determine the influence of fixation method (internal vs. external) on short-term postoperative complications of closed diaphyseal tibial fractures in skeletally immature dogs. Retrospective observational multicenter study. Skeletally immature dogs stabilized with internal fixation (IF) via plate osteosynthesis (n = 59) and external skeletal fixation (ESF) (n = 36). Medical records from skeletally immature dogs with closed tibial diaphyseal fractures were reviewed. Data collected included signalment, fracture morphology, etiology, fixation technique, surgeon status, complications, time to discharge and time to final discharge. The total complication rate for IF was lower at 20.3% (p < .001, CI: 11.0-32.8) compared to ESF at 55.6% (CI: 38.1-72.1). A total of 95% of complications were considered major for external fixation versus 75% for internal fixation. Multivariable analysis revealed decreased odds of a postoperative short-term complication when a closed tibial diaphyseal fracture was stabilized with IF compared to ESF (p = .004, OR: 0.2, CI: 0.09-0.63). The median time to final discharge for ESF was 4 weeks (range: 2-13) and for IF was 6 weeks (range: 4-32) (p = .01). ESF had a higher rate of short-term complications than IF, primarily due to pin-tract morbidity. The complication rate was 35.3% higher for ESF than for IF. Surgeons should consider the use of IF over ESF for skeletally immature dogs to reduce the risk of major complications.

Closed reduction and percutaneous pinning (CRPP) is a promising treatment for pediatric lateral condyle humerus fractures (LCHFs) displaced >4 mm. However, few studies discussed roles of fracture types on success of CRPP in LCHFs. This study aimed to analyze the impacts of types of LCHFs displaced >4 mm on the success rate of CRPP. We retrospectively reviewed 66 consecutive pediatric LCHFs attempted CRPP at our center. Song, Milch, Jakob, and Weiss classification were used to classify LCHFs. The fracture gap ≤2 mm and step of articular surface ≤2 mm were deemed as a successful CRPP. Otherwise, open reduction and internal fixation (ORIF) would be performed. Different fracture types and preoperative displacement were analyzed for their roles on success rate of CRPP in treating LCHFs displaced >4 mm. Fifty patients met the inclusion criteria were finally included in this study. Results showed that Milch type II LCHFs had a higher success rate of CRPP than type I LCHFs (P=0.03, <0.05). Correlation was found between Milch types and success rate of CRPP displaced >4 mm. No difference was found between Song stage 4 and 5 LCHFs displaced >4 mm in success rate of CRPP (P=0.90, >0.05), also no difference was found in pre-operative displacement between CRPP group and ORIF group. Milch classification is more important than Song classification in the success rate of CRPP when treating LCHFs displaced >4 mm. Milch type II LCHFs are recommended to be treated with CRPP, while Milch type I LCHFs are recommended to be treated with ORIF. The current study confirm Song's initial report that closed reduction can be successful and should be attempted for fractures with such displacement rather than going directly to ORIF. Level III.

What's New in Limb Lengthening and Deformity Correction.

Background and purpose We have previously shown in a randomized study that in the first year after treatment, open reduction and internal fixation resulted in better grip strength and forearm rotation than closed reduction and bridging external fixation. In the present study, we investigated whether this difference persists over time.Patients and methods The 50 patients included in the original study (mean age 53 years, 36 women) were sent a QuickDASH questionnaire and an invitation to a radiographic and clinical examination after a mean of 5 (3–7) years.Results All 50 patients returned the QuickDASH questionnaire and 45 participated in the clinical and radiographic examination. In the internal fixation group, the grip strength was 95% (SD 12) of the uninjured side and in the external fixation group it was 90% (SD 21) of the uninjured side (p = 0.3). QuickDASH score, range of motion, and radiographic parameters were similar between the groups.Interpretation The difference originally found between internal and external fixation in distal radial fractures at 1 year regarding grip strength and range of motion was found to diminish with time. At 5 years, both groups had approached normal values.

Supracondylar humerus (SCH) fractures are some of the most common fractures in pediatric patients with surgery typically consisting of either open or closed reduction with internal fixation. The aim of this meta-analysis was to identify patient, injury, and administrative factors that are associated with treating pediatric SCH fractures with open techniques. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, PubMed and CINAHL database searches were conducted for studies from 2010 to 2023 that made direct comparisons between open reduction and internal fixation (ORIF) and closed reduction and percutaneous pinning (CRPP) for treating SCH fractures in the pediatric population. The search terms used were "pediatric" AND "SCH fracture" OR "distal humerus fracture." Screening, quality assessment, and data extraction were performed by 4 reviewers. After testing for heterogeneity between studies, data were aggregated using random-effects model analysis. Forty-nine clinical studies were included in the meta-analysis. Summated, there were 94,415 patients: 11,329 treated with ORIF and 83,086 treated with CRPP. Factors that were significantly associated with greater rates of ORIF included obesity (p = 0.001), Gartland type IV fractures (p < 0.001), general neurological deficits (p = 0.019), and ulnar nerve deficits (p = 0.003). Gartland type II (p = 0.033) and medially displaced fractures (p = 0.011) were significantly associated with lower rates of ORIF. Secondary analysis showed cross-pinning constructs (p = 0.033) and longer hospital stays (p = 0.005) are more likely to be observed in patients undergoing ORIF compared with CRPP. This meta-analysis demonstrates that factors such as obesity, fracture displacement, and concomitant nerve deficits are more likely to require ORIF as opposed to CRPP. Therapeutic Level III.

The Limb Lengthening and Reconstruction Society (LLRS) celebrated its 28th year as an orthopaedic subspecialty, with a combined meeting with the Pediatric Orthopaedic Society of North America (POSNA) at the 2019 American Academy of Orthopaedic Surgeons (AAOS) meeting in Las Vegas. The LLRS 28th Annual Scientific Meeting was held on July 19 and 20, 2019, in Boston, Massachusetts, featuring papers and workshops from around the world. A diverse subspecialty society, we overlap with trauma, pediatric, foot and ankle, sports, arthroplasty, and oncologic orthopaedic surgeons in the diagnosis and treatment of deformities of length, alignment, contracture, nonunion, and bone healing. The purpose of this update was to summarize the important articles with regard to these subjects published since 2018. Guided Growth The technique of temporary, asymmetric growth plate tethering continues to be a successful method of deformity correction in growing children. The concept, known as guided growth, was developed by Dr. Peter Stevens, using a small, 2-hole plate to span the growth plate on 1 side, allowing the opposite side to grow unresisted, and thereby correcting angular deformity without osteotomy. The screws within the plate provide an articulation, with the apex of the correction occurring at the perichondrial ring. A multinational retrospective study described results of guided growth in 537 children with 967 physes treated1. Distal femoral and proximal tibial correction rates were similar, averaging 0.77° per month for the distal part of the femur and 0.79° for the proximal part of the tibia, despite the commonly held opinion that the femur corrects faster than the tibia. Patients with >3 years of growth remaining had a better quality of correction. Infection was uncommon, occurring in 1.78% of patients. Seven of the 8 infections occurred at the upper medial part of the tibia. The study was unable to correlate the effect of body weight on the result, nor did it assess the incidence of rebound deformity. A modified guided growth technique has been previously advocated for only removing the metaphyseal screw and leaving the plate and epiphyseal screw in place once a correction is complete. Thus, in the event that a deformity recurs, a simpler procedure to reinsert a single screw could be performed. A study by Keshet et al. refuted this practice2, as they observed permanent bar formation in 2 of 55 cases using the technique. They also observed that only 12 of their 55 patients required reinsertion of the metaphyseal screw and that 9 of those actually required plate repositioning. Anterior guided growth of the distal part of the femur to treat fixed knee flexion contracture in cerebral palsy has been reported to have favorable results, provided that implants are placed sufficiently anterior and adequate growth remains3. Congenital Pseudarthrosis of the Tibia Congenital pseudarthrosis of the tibia remains a challenge for the orthopaedic surgeon. Richards and Anderson4 reported using bone morphogenetic protein (BMP)-2 without deleterious effects in 21 children with congenital pseudarthrosis. They applied a single sponge around an autologous cancellous bone graft with intramedullary pinning that crossed the ankle joint. This technique seemed to shorten the time to union, but did not eliminate nonunion or refracture, the latter occurring in 5 of the 16 initially healed patients. In a retrospective multicenter study of 119 patients with Crawford type-II congenital pseudarthrosis of the tibia followed to maturity, Shah et al. reported an 86% primary union rate, with 69% still united at maturity5. They did not identify specific factors influencing rates of union or refracture and recommended a larger, prospective, multicenter study. Three-Dimensional Printing Three-dimensional printing, originally known as additive manufacturing, creates models by printing layers of materials on top of one another. These models can be physically held, manipulated, and studied, providing the surgeon preoperative assessment of the specific anatomical geometry. Haleem and Javaid6 described methods to create 3-dimensional models for preparation and practice of orthopaedic procedures. Exact fit models, based on magnetic resonance imaging (MRI) or computed tomography (CT) scanning techniques, can allow for preoperative planning and mock surgical procedures and can create implants specific for complex cases. Corona et al.7 described using 3-dimensional printed titanium truss cages in conjunction with the Masquelet technique to treat massive infected posttraumatic defects. Bone Defects Nauth et al.8 described a 3-stage protocol of (1) radical debridement and resection of infected skeletal elements; (2) defect space management using antibiotic blocks, spacers, or beads, which provide a local depository of culture-specific antibiotic and develop a vascularized membrane; and (3) 8 weeks later, carefully opening the membrane and exchanging the spacer for an autologous graft. Napora et al.9 described excellent functional outcome of patients at 2 to 8 years after tibial defects were treated with bone transport using a stacked hexapod frame. Corticotomy and transport were delayed for 6 to 8 weeks in patients undergoing concurrent flap coverage. The authors noted improved ease and accuracy of the docking with hexapod frames and described a method to augment frame stability near the end of treatment. The Short Musculoskeletal Function Assessment (SMFA) score was not influenced by age, sex, or diabetic status. Seventeen of 38 patients required an additional fixation surgical procedure (plate, nail, or fixator reapplication) at some point during their treatment. Barinaga et al.10 published a case report of successful tibial bone transport combining the use of a motorized magnetic lengthening nail and a limited contact dynamic compression plate, sparing the patient adjunctive external fixation. Limb Lengthening Distraction osteogenesis is the spontaneous formation of new bone in a gradually widening osteotomy site using external fixation. The more recent development of motorized internal limb-lengthening nails has advanced the capabilities of treating patients with limb lengthening and reconstruction needs. Additional authors have reported safe and successful lengthening with motorized intramedullary devices. Iobst et al.11 reported on simultaneously performing distal femoral angular correction and insertion of a retrograde intramedullary lengthening nail, while controlling the fragments with a temporary intraoperative external fixator. Length was subsequently achieved with the motorized intramedullary lengthening nail. Acute corrections of up to 15° were possible with the technique. The authors preoperatively planned their cases using the Baumgart method of reverse planning. Magnetic lengthening nails were used with liberal application of blocking screws preventing postoperative deformity. A cost study suggested that patients undergoing intramedullary lengthening have higher initial implant costs than fixator lengthening over a nail, but the former undergo fewer procedures overall12. Reuse of a PRECICE nail (Nuvasive) was reported in a case of a femoral discrepancy after an infection in which a 3-cm lengthening was successfully performed, distal locking screws were removed, the telescopic portion of the nail was retracted, and a second corticotomy and lengthening were performed13. Radiographic evaluation of bone regenerate formation during lengthening is possible by a number of means. A radiographic pilot study by Vulcano et al.14 found that a pixel-density ratio of >0.89 (ratio of pixel density in the regenerate relative to the surrounding cortex) may correlate with osseous healing and may be the threshold for allowing full weight-bearing. In pediatric patients, Archer et al.15 also found that the most reliable radiographic assessments of regenerate were by the pixel value ratio and the Ru Li technique. The mechanical environment of distracted callus affects the quality of new bone formation. An ovine study was performed by Claes et al.16 in which lateral callus distraction was undertaken in tibiae and various cyclic loads were applied at the end of lengthening. Tibiae that underwent compressive loading had more bone formation, higher spicule height, and higher blood vessel density than those experiencing shear or distractive loading. Growth Prediction Makarov et al.17 evaluated 77 patients at their institution, comparing the predictive accuracy of the White-Menelaus, Anderson-Green, Moseley, and multiplier methods for correctly timing epiphysiodesis. Final leg-length prediction errors varied from 0.7 to 1.1 cm, with the multiplier method proving to be the least accurate. Makarov et al.18 also reported a 7% complication rate among 863 epiphysiodeses, the most common of which was incomplete arrest in 31 patients resulting in angular deformity and requiring reoperation in half of such cases. Physeal Violation A sheep model was used by Knapik et al.19 to assess the consequences of distal femoral physeal violation by a retrograde intramedullary implant, noting that violations of ≤7% of the cross-sectional area were associated with continued growth of the physis without bar formation. Congenital Limb Deficiencies A review from the Finnish Register of Congenital Malformations and Care Register for Health Care20 identified all children born with lower-limb deficiencies, comparing their hospital admissions and stays with the general pediatric population of Finland. In the 16-year study period, the authors found that children with lower-limb deficiencies (terminal, long bone, foot, and toe) had 6 times the number of hospital admissions and 10 times the number of days in the hospital per child than all of the children born without limb deficiency. Two-thirds of the patients born with congenital lower-limb deficiencies required an operation, and approximately half of those operations were orthopaedic. The ratio of the short lower extremity to the contralateral, longer lower extremity in patients with congenital deficiencies has historically been considered constant in the orthopaedic literature. Tsai et al.21 attempted to verify this concept of constant inhibition and to further elucidate the pattern of skeletal maturation in patients with fibular hemimelia. They confirmed the concept of constant inhibition, with a mean deviation ranging from 0.1% to 3.3% in the femur and 0.1% to 3% in the tibia. They also noted that the growth patterns of the lower extremities in patients with unilateral fibular hemimelia did not differ when compared with the normal population. Kowalczyk and Kuźnik-Buziewicz22 reported outcomes of rotation-plasty for unilateral proximal femoral focal deficiency, reviewing postoperative function, time to knee fusion, and complications in 8 adolescents followed for 6 to 12 years postoperatively. Intensive preoperative physical therapy was performed to maximize strength and motion, especially ankle dorsiflexion. Patients were all pain-free and were able to walk without assistive devices. The 2 patients who did not exhibit a Trendelenburg gait had undergone preoperative hip stabilization procedures. Spontaneous derotation of the foot occurred in 5 of 8 patients, necessitating a repeat surgical procedure in 2 patients. All patients reported acceptance of the limb appearance and satisfaction with the result. Radhakrishna et al.23 reviewed 6 patients with Jones type-II tibial hemimelia presenting with an absent distal part of the tibia who were treated with limb salvage. All patients were reconstructed with the following elements: gradually moving the fibula distally using an external fixator to normalize the relationship of the proximal parts of the tibia and fibula; centralizing the fibula with creation of a synostosis between the fibula and tibia; and centralizing the foot relative to the fibula distally, creating a fibular-talar fusion, using external fixation and soft-tissue releases. The mean increase in leg length was 4 cm, with a mean time of 43 days in the fixator. Each child required 2 to 4 procedures, with all patients achieving union. Walker et al.24 analyzed a group of patients with ulnar deficiency and noted that a lower-extremity deficiency was present in 55% of patients. The patients with lower-extremity deficiencies and ulnar deficiencies had less severe presentation of ulnar deficiency. The authors observed no patients with tibial hemimelia (pre-axial deficiency) associated with ulnar deficiencies (post-axial deficiency). They pointed out that the upper-limb bud forms earlier than the lower-limb bud, considering the possibility that a developing limb insult would explain the observation that more lower-extremity involvement was related to less upper-extremity involvement. Physeal Arrest and Epiphysiodesis Physeal bar formation was assessed in a rat model by Wattenbarger et al.25. They selectively induced injury by scraping and drilling the metaphyseal and epiphyseal sides of the physis. Basement plate penetration on the epiphyseal side was associated with radiographic and histologic physeal injury, whereas hypertrophic zone violation on the metaphyseal side was associated with continued growth. Arthroscopic and navigation-assisted physeal bar resection is being increasingly reported. Miyamura et al.26 reported a case with a 2-year follow-up of a distal radial bar excision and concomitant osteotomy, planned using 3-dimensional CT, patient-specific guides, and intraoperative endoscopic visualization. Foot and Ankle Ankle arthrodesis for neuropathic foot deformity is historically associated with poor union rates. A fusion technique combining an external fixator and an intramedullary nail was reported to achieve fusion in 22 of 24 patients by El-Mowafi et al.27. Neuropathic foot deformity with concurrent osteomyelitis is the subject of an article by Kliushin et al.28. Seventy-seven patients were treated for a mean time of 180 days in an external fixator, with infection eradicated in 90.9% of patients at a 1-year follow-up. The American Orthopaedic Foot & Ankle Score (AOFAS) increased marginally, which the authors attributed to the pain component of the outcome score. Brandão et al.29 discussed the management of diabetic neuropathy of the foot with both internal and external fixation techniques, with particular attention to the concept of beaming of the midfoot with axial internal fixation. This concept was described as stiff, thick, intramedullary longitudinal support from hindfoot to forefoot. Staged distraction osteogenesis and ankle arthrodesis were performed by Lou et al.30 in 12 patients with posttraumatic or infectious bone loss of the distal part of the tibia who were treated with simultaneous proximal lengthening and distal compression osteosynthesis using circular fixation to provide ankle fusion. The AOFAS improved from a mean of 37.3 to 75.3 points, and successful regenerate was formed in all, although 2 patients underwent bone-grafting. Ahmad et al.31 reported the results of the treatment of rigid equinus foot deformity with circular external fixation in an adolescent and pediatric population. They reported a mean correction angle of 47.4°. Pin-track infections occurred in 4 of the 30 patients. Equinus deformity secondary to burn contractures treated with circular external fixation was the subject of a report by Zhang et al.32. The authors described a wire technique in the foot, predominantly using hindfoot wires, recognizing the need to avoid injury to the posterior tibial neurovascular bundle. A cadaver study by Kelly et al.33 identified safe hindfoot wire insertion using an entry point one-third of the distance along a line from the posterior aspect of the calcaneus to the lateral malleolus to predictably avoid the posteromedial neurovascular bundle. Nepalese children who were 1 to 5 years of age and had neglected clubfoot deformity were treated by the Ponseti method34. Ninety-five percent of feet remained plantigrade at a minimum of 10 years. Despite some residual deformity, patient-reported outcomes were satisfactory, with a relapse rate of 3%. Trauma The role of external fixation in the management of tibial fractures was described in a number of publications. In a retrospective study, Berven et al.35 compared Ilizarov frame fixation with locking plate fixation of proximal tibial fractures between 62 patients treated at 1 center using the Ilizarov technique and 68 patients treated at a different institution using internal fixation. Time to union was considered faster in the internal fixation group. Deep infection, alignment, reoperation, and range of motion were similar in the 2 groups. Lovisetti et al.36 reported the results of circular external fixation in bicondylar tibial plateau fractures, with a mean follow-up period of 37.3 months. All 20 cases were initially managed with knee-spanning fixation. The results were measured by radiographs and Hospital for Special Surgery (HSS) score and were described as favorable when compared with other series presented in the literature. Napora et al.9 examined functional outcomes in 38 patients with infected tibial nonunion managed with stacked hexapod external fixators for the purpose of bone transport. Corticotomy and transport were delayed for 6 to 8 weeks in patients undergoing concurrent flap coverage. The study noted that, with an intact fibula, the proximal and distal portions of the frame programs must be a mirror image of each other and that if angular, translational, rotation, or additional length deformity correction is built into the frame, a fibular osteotomy is required. Patients completed an SMFA survey at the time of final follow-up. The SMFA score was not influenced by age, sex, or diabetic status. Of 38 patients, 17 required an additional fixation surgical procedure (plate, nail, or fixator reapplication) at some point during their treatment. Arsoy et al.37 reported that patients presumed to have aseptic nonunion but later determined to have positive cultures had an 84% union rate with systemic antibiotic therapy. Tumor Elalfy et al.38 determined that chemotherapy had a negative effect on bone healing and diminished bone hypertrophy when using modulated compliant compressive forces to induce osteointegration in a tumor prosthesis. The 49 patients receiving chemotherapy postoperatively had less bone formation than the 44 patients who did not receive chemotherapy. Implant survival was not affected by chemotherapy, with 10-year survival rates of 85%. Limb-salvage techniques in the management of pediatric sarcoma continue to evolve. Segmental metadiaphyseal distal femoral defects after resection can be reconstructed with a novel vascularized fibular A-frame technique, augmented with an intramedullary nail. This provides a biological reconstruction with greater cross-sectional area than a single vascularized fibula, with a segment amenable to later limb lengthening39. For patients with limb growth potential remaining who require endoprosthetic reconstruction, growing prostheses are described. These include both minimally invasive devices (requiring lengthening under fluoroscopic guidance) and noninvasive devices (driven by an external magnet), and these were compared in a survival analysis by Medellin et al.40. Prosthesis survival was demonstrated as 79% (minimally invasive) and 70% (noninvasive) at 10 years. Patients receiving noninvasive prostheses had a higher mean Musculoskeletal Tumor Society Score (27 points) compared with patients who received minimally invasive devices (24.7 points), which, although not attaining significance (p = 0.295), was attributed by the authors to higher patient satisfaction, better gait, and greater independence. A novel approach to limb salvage in sarcoma of the distal part of the tibia was also described by Lou et al.30, with 5 patients undergoing resection of tumor (including the distal part of the tibia and the talar chondral surface) and subsequent tibial bone transport to achieve tibiotalar fusion. The segment was plated 1 month following the transport phase to expedite frame removal, with mean final Musculoskeletal Tumor Society Score of 88 points.

PurposeThe aim of this study was to evaluate the feasibility of anterior pelvic ring fixation alone for treating lateral compression type 1 (LC-1) fractures with nondisplaced complete sacral fractures.MethodsPatients with LC-1 type pelvic fractures with nondisplaced complete sacral fractures in the Xi’an Honghui Hospital were screened. Those who underwent surgical treatment for the anterior pelvic ring fractures and conservative treatment for the sacral factures were included in the analysis. The Majeed and Short Form-12 (SF-12) functional scores were used to evaluate these patients.ResultsOf the 123 patients enrolled, 108 (88%) responded to our enquiries regarding the outcome. The mean follow-up period was 18.37 months for the 108 patients who responded. The mean SF-12 functional score was 48.22 ± 9.68. The mean Majeed score was 83.47 ± 9.23, including 52 with excellent, 47 with good, seven with fair, two with poor outcomes. The SF-12 functional and Majeed scores were significantly higher in those aged <45 years or without lower limb injury than in those aged ≥45 years or with lower limb injury (P < 0.05).ConclusionAcceptable functional outcomes can be obtained for LC-1 pelvic fractures with nondisplaced complete sacral fractures by using anterior pelvic ring fixation alone.

To investigate the effectiveness of Wiltse approach with fulcrum reduction technique and pedicle internal fixation in the treatment of AO-A type thoracolumbar fractures. The clinical data of 16 patients with AO-A type thoracolumbar fractures treated with Wiltse approach with fulcrum reduction technique and pedicle internal fixation between September 2013 and January 2019 were retrospectively analyzed. There were 9 males and 7 females, the age ranged from 38 to 60 years, with an average age of 50.7 years. Causes of injury included 9 cases of falling from height, 3 cases of traffic accidents, 3 cases of falling, and 1 case crushed by heavy objects. Fractured segment involved T 11 in 2 cases, T 12 in 5 cases, L 1 in 7 cases, and L 2 in 2 cases. There were 6 cases of type A1, 3 cases of type A2, 5 cases of type A3, and 2 cases of type A4 according to AO fracture classification. The operation time, intraoperative blood loss, and removal time of internal fixator were recorded. Before operation, immediately after operation, before and after removal of internal fixator, the local kyphotic angle (LKA), anterior vertebral height (AVH), and posterior vertebral height (PVH) of fractured vertebral body were measured; visual analogue scale (VAS) score of back pain were evaluated before operation, at 3 days after operation, before and after removal of internal fixator. The operation time of the patients was 50-95 minutes, with an average of 70.7 minutes; the intraoperative blood loss was 50-230 mL, with an average of 132.9 mL; the internal fixator was removed after 18-30 months, with an average of 23.6 months. All patients were followed up 20-32 months, with an average of 25.6 months. No incision infection, hematoma, and other surgery-related complications, and internal fixator rupture residual complications occurred. All 16 patients achieved satisfactory reduction results. Immediate postoperative LKA, AVH, and PVH were significantly improved when compared with preoperative ones ( P<0.05). There was a certain degree of reduction loss before internal fixator removal, and the difference in LKA was significant ( P<0.05), but the difference in AVH and PVH were not significant ( P>0.05). There was a certain degree of reduction loss after internal fixator removal, but only the difference in AVH was significant ( P<0.05), and there was no significant difference in LKA and PVH ( P>0.05). The VAS score of the back pain significantly improved at 3 days after operation and before internal fixator removal when compared with preoperative score ( P<0.05). The pain after internal fixator removal was significantly worse than that before internal fixator removal ( P<0.05). The Wiltse approach with fulcrum reduction technique and pedicle internal fixation in the treatment of AO-A thoracolumbar fractures has a short operation time, less intraoperative blood loss, and the posterior soft tissue and other structures are well protected during the operation. It can provide satisfactory clinical reduction results.

Classic bladder exstrophy (BE) is regarded as an isolated malformation without any further anomalies, but some studies have indicated a higher incidence of cardiac anomalies. This cross-sectional study is planned to evaluate the prevalence of congenital heart defects (CHDs) and the clinical relevance for patients with BE admitted for primary closure. Patients were prospectively recruited between March 2012 and January 2019. Patients' profiles including demographic data, results of transthoracic echocardiography (TTE), as well as essential peri- and postoperative data were assessed. Thirty-nine (25 boys and 14 girls) patients with BE (median age 61 days) underwent delayed primary bladder closure. Thirty-seven (24 boys and 13 girls) patients had received TTE 1 day before surgery. CHD was detected in 7 (18.9%) out of the 39 patients, but no clinical differences between patients with and without CHD were observed peri- or postoperatively. This prospective systematic evaluation shows an even higher rate of CHD in patients with BE than assumed previously. Although peri- and postoperative outcome did not differ between patients with and without CHD, we consider TTE an important additional method for ensuring a safe peri- and postoperative courses and a short- and long-term care for patients with CHD.

Category:Ankle Arthritis, Diabetes, HindfootIntroduction/Purpose:Charcot neuropathy of the ankle and hindfoot is a progressive and destructive process that can lead to instability and ulceration resulting in significant morbidity which can end with amputation. The foot and ankle surgeon’s aim is to reconstruct the high risk foot with the creation of a stable plantigrade foot, while reducing the risk of ulceration and allowing the patient to mobilize in commercially available footwear. There are numerous techniques for the reconstruction of the neuropathic hindfoot, but the most utilized of these include multiplanar external fixation or internal fixation with a plate or intramedullary nail. It is our goal to further elucidate outcomes of Charcot patients undergoing corrective ankle and hindfoot fusion comparing internal versus external fixation.Methods:We retrospectively collected 377 patients undergoing hindfoot and ankle arthrodesis at our institution from 2006- 2017. 77 patients were identified that underwent arthrodesis for Charcot arthropathy, 56 of which met our inclusion and exclusion criteria. This included 47 who had internal fixation as their primary procedure and 9 patients who underwent external fixation with a multi-planar external fixator. Our median follow up time was 3.4 years (IQR .5 to 12.9). Preoperatively we collected basic demographic variables, reasons for neuropathy, and ulcer status. Postoperatively we collected complications including infection, hardware failure, ulceration, recurrent deformity, and radiographic outcomes including union and hardware backout. Reoperation numbers and indications were also collected. Our primary outcome was limb salvage at final follow up.Secondarily, we collected final ambulatory and footwear status.Results:The limb salvage rate was 82% with 10 patients undergoing amputation, which did not vary between groups (p=.99). The primary reasons for amputation were persistent infection (4 of 10) and nonunion (4 of 10). Thirteen (24%) patients developed an infection. The median number of reoperations per patient was 1 (IQR 0-2) with the patients who underwent amputation undergoing a median of 2 (IQR 2-4) reoperations. The rate of union was 54%, occurring at a median of 26.5 (IQR 12-47) months. 44% (4/9) of patients in the external fixation group had a preoperative ulceration versus 19% (9/47) of the patients in the internal fixation group (p=.19). Preoperative ulceration was not a risk factor for amputation. Forty-two (75%) patients were ambulatory at final follow up.Conclusion:We report on the single largest series of Charcot patients undergoing hindfoot and ankle arthrodesis. The surgical management of this population has a high rate of complications with infection and reoperation being common. Despite a high nonunion rate most patients are able to ambulate in a brace or orthotic. Limb salvage can be expected with either internal or external fixation techniques.

The treatment of unstable pelvic ring fractures, markedly comminuted and displaced acetabular fractures and combinations of these insults to the pelvis is an unsolved problem. Of all the previously described methods, external fixation has appeared to hold the most promise for certain pelvic bone injuries of major proportions which are accompanied by instability of the pelvic ring. Many of the external fixation devices of the past have not provided adequate stability. A modification of the Hoffmann external frame provides a simple method of treatment for unstable pelvic ring fractures that immediately permits the patient to move from bed to chair. Complex pelvic and central acetabular fractures also are responsive to treatment by extensive external frames. While this external skeletal fixation is superior to previously available devices, internal fixation is under consideration for stabilization of the posterior portion of the pelvic ring. A combination of internal and external fixation may also be advantageous for severely disrupted pelvic bones.